How Does Infection Prevention Fit Into a Safety Program?

by Susan S. Huang, MD, MPH

Perspective

In 1999, the Institute of Medicine (IOM) released the To Err is Human: Building a Safer Health System report.(1) This publication ignited the nation's efforts to address unintended consequences that were occurring as a result of patients seeking medical care in United States hospitals. The impact of these errors was likened to a 747 airplane crashing every day. A substantial portion of the harm from errors occurred in the form of preventable health care–associated infections (HAIs). More recently, the cost of these infections was estimated to be up to 10 billion dollars annually.(2)

While the IOM report spurred the public and health care profession to focus on medical mistakes in general, and HAIs more specifically, the story of initiatives to prevent infections has been a longstanding effort that benefited greatly from a nation galvanized to change. The field of infection prevention began to emerge in the 19th century, when Semmelweiss showed that providers could protect mothers from death during childbirth by washing their hands. That century also saw the emergence of Lister's surgical sterility and Louis Pasteur's germ theories.

Yet, it was not until the 1960s and 1970s that infectious diseases and infection prevention organizations began to materialize, in the form of the Infectious Diseases Society of America in 1963, the Association for Professionals in Infection Control and Epidemiology in 1972, and the Society for Healthcare Epidemiology of America in 1980. In the mid-1970s, the SENIC (Study on the Efficacy of Nosocomial Infection Control) project found that hospitals with dedicated physician leadership and a minimum of 1 trained infection prevention expert per 100 licensed acute care hospital beds had significantly lower rates of hospital infections.(3)

A critical milestone for infection prevention was the establishment of formal infection prevention and control programs under health care facility operations, in all clinical settings. The role of these programs was to prevent both HAIs in patients and infections in health care workers. In hospitals, for example, the scope of these programs rapidly expanded to encompass all areas of patient safety related to infection prevention, including tracking and responding to contagious and virulent pathogens (e.g., endemic and emerging multidrug-resistant organisms, C. difficile, influenza, and other respiratory viruses); providing for relevant precautions (e.g., contact, droplet, or airborne protective) and personal protective equipment; instituting surveillance and prevention of device-associated infections (e.g., central lines, urinary catheters, ventilators, surgical implants, hemodialysis) and surgical site infections; implementing outbreak and infectious exposure response; vaccinating health care workers; conducting infection prevention for disinfection, sterilization, and reprocessing; instituting environmental cleaning; overseeing construction projects for infectious containment; performing food safety; developing educational materials for patients and health care workers; instituting hospital policies; monitoring compliance; mandatory reporting to state and national agencies; and ensuring emergency and pandemic preparedness (Table). The expansive role of infection prevention in inpatient and outpatient settings has resulted in the establishment and requirement for a dedicated team consisting of physician-epidemiologists trained in both infectious diseases and epidemiology and certified non-physician infection preventionists to ensure appropriate oversight and improvement.

In many ways, infection prevention efforts have been a model for comprehensive safety programs that extend well beyond infection prevention. Because of this, it is worth reflecting on the growth and development of such programs; this history may hold important lessons for the patient safety field.

First, and as described above, it was essential to define the composition, scope, and operational funding for infection prevention and control programs. This was followed by development of training and certification programs (4,5) along with numerous guidelines established and maintained by the Healthcare Infection Control Practices Advisory Committee, a group of 14 experts that provides advice and guideline development for the Department of Health and Human Services regarding surveillance and practice of health care infection control and prevention.(6)

Second, the vision and infrastructure for national surveillance and reporting systems for HAIs was born. Initially voluntary, the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network was rapidly adopted by state mandates and Medicare pay-for-reporting requirements. Currently, it serves as the vehicle through which approximately 12,000 US medical facilities (e.g., hospitals, nursing homes, ambulatory surgical centers, hemodialysis units) report numerous HAIs. The systematic collection of these data and provision of reports allows for local, state, and national benchmarking and inter-facility comparisons.(7,8) The fundamental epidemiologic need for well-defined and objective surveillance criteria continues to be provided and enhanced by the CDC.

Third, the public outcry for transparency and advocacy galvanized the field in the late 1990s and early 2000s and continues to drive the field of infection prevention forward. As a result of this pressure, Government Accountability Office reports (9,10) and a US Health and Human Services HAI Action Plan (11) were commissioned, which ultimately fueled state mandates (12) for public reporting of hospital HAI rates. Moreover, these reports and growing public concern about HAIs led to several federal programs tying reimbursement to reporting and performance to reduce HAI events.(13-16) In the face of widespread mandates for public reporting and integration of HAI rates into payment policies, the need for formal state and national validation systems to ensure fair and objective reporting was identified; such systems are still in evolution today.(17)

Fourth, the need for scientific evidence to reduce HAIs led to federal and philanthropic investments in surveillance and prevention strategies. Initial expansions in funding from federal agencies (National Institutes of Health, Agency for Healthcare Research and Quality, and CDC) as well as the recently established Patient-Centered Outcomes Research Institute have helped identify novel solutions to reduce HAIs still further. Private non-profit agencies and health insurers have also propelled discovery and dissemination. Funding has enabled major advancements in the field of HAI research, including quasi-experimental design (cross-over and stepped wedge designs) and cluster-randomized trials to evaluate the comparative effectiveness of quality improvement strategies. The recent decline in federal research dollars threatens the efforts to develop new methods to protect patients from infection. Further investment is also needed to enhance gains in change theory, implementation science, dissemination, validation, and ethical oversight.

In summary, infection prevention and control programs are a critical and longstanding component of broader efforts to ensure the safety of patients in the health care system. The field of infection prevention serves as a prime example of how transparency and patient advocacy, coupled with national surveillance systems and federal investments, can lead to important gains in our efforts to eliminate emerging and existing infectious threats to patients in health care facilities.

Susan S. Huang, MD, MPH
Division of Infectious Diseases and Health Policy Research Institute
University of California, Irvine, School of Medicine

References

1. Kohn L, Corrigan J, Donaldson M, eds. To Err is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine. National Academies Press; 1999. ISBN: 9780309068376.

2. Zimlichman E, Henderson D, Tamir O, et al. Health care–associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173:2039-2046. [go to PubMed]

3. Haley RW, Quade D, Freeman HE, Bennett JV. The SENIC Project. Study on the efficacy of nosocomial infection control (SENIC Project). Summary of study design. Am J Epidemiol. 1980;111:472-485. [go to PubMed]

4. Milwaukee, WI: Certification Board of Infection Control and Epidemiology, Inc. [Available at]

5. SHEA-CDC Training Course in Healthcare Epidemiology. Society for Healthcare Epidemiology of America. [Available at]

6. General Guidelines. Healthcare Infection Control Practices Advisory Committee (HICPAC). Atlanta, GA: Centers for Disease Control and Prevention. [Available at]

7. Jarvis WR. Benchmarking for prevention: the Centers for Disease Control and Prevention's National Nosocomial Infections Surveillance (NNIS) system experience. Infection. 2003;31(suppl 2):44-48. [go to PubMed]

8. National Healthcare Safety Network. Atlanta, GA: Centers for Disease Control and Prevention. [Available at]

9. Healthcare-Associated Infections in Hospitals. Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on These Infections. Testimony before the Committee on Oversight and Government Reform, House of Representatives. US Government Accountability Office. GAO-08-673T (April 16, 2008) (testimony of Cynthia A. Bascetta). [Available at]

10. Healthcare-Associated Infections in Hospitals. An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections. Report to the Chairman, Committee on Oversight and Government Reform, House of Representatives. US Government Accountability Office. GAO-08-808 (September 5, 2008). [Available at]

11. National Action Plan to Prevent Health Care–Associated Infections: Roadmap to Elimination. Washington, DC: US Department of Health and Human Services. [Available at]

12. Legislative Maps. Washington, DC: Association for Professionals in Infection Control and Epidemiology. [Available at]

13. Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System. Federal Register. Centers for Medicare & Medicaid Services. 42 CFR Parts 412, 413, 424, and 476: August 31, 2012. [Available at]

14. Hospital Value-Based Purchasing. Baltimore, MD: Centers for Medicare & Medicaid Services. [Available at]

15. Delivery System Reform Incentive Payments (DSRIP). Sacramento, CA: California Department of Health Care Services. [Available at]

16. Texas Health Care Transformation and Quality Improvement Program. Austin, TX: Texas Hospital Association. [Available at]

17. Talbot TR, Bratzler DW, Carrico RM, et al; Healthcare Infection Control Practices Advisory Committee. Public reporting of health care–associated surveillance data: recommendations from the Healthcare Infection Control Practices Advisory Committee. Ann Intern Med. 2013;159:631-635. [go to PubMed]

Table

Table. Scope of Work of Hospital Infection Prevention Programs.

(Go to table citation in the text)

Areas of Responsibility	Examples
Routine Monitoring and Surveillance for Imported and Hospital-Acquired Pathogens	Multidrug-resistant organisms* (MRSA, VRE, ESBL, CRE, other MDR GNR)
	Tuberculosis
	Fungal disease (e.g., aspergillus)
	Respiratory illness (e.g., influenza)
	C. difficile infection
Routine Monitoring and Surveillance for Health Care–Associated Infections	Central line–associated bloodstream infection (CLABSI)
	Catheter-associated urinary tract infection (CAUTI)
	Ventilator-associated complication (VAC)
	Surgical site infection (SSI)
	Hemodialysis
	Adverse and sentinel events involving HAIs
Reporting	CDC National Healthcare Safety Network
	Public reporting by state legislative mandate
	Pay-for-reporting by Centers for Medicare & Medicaid Services
	Local and state public health (reportable diseases)
	Others (e.g., Medicaid, Leapfrog, Magnet, University HealthSystem Consortium, Consumer Reports)
Oversight of Processes and Protocols	Hospital policies related to infection prevention
	Compliance monitoring (e.g., hand hygiene, separation of clean and dirty, adherence to precautions)
	Proper application of precautions (standard, airborne, droplet, or contact protective)
	Proper use of personal protective equipment
	Environmental cleaning
	Sterilization and disinfection, re-processing
	Construction-related infectious containment (e.g., dispersal of fungal spores)
	Food safety
	Infection safety of water features (e.g., fountains, green walls)
Education	Patient education for infection prevention
	Annual infection prevention training for staff
	Communicable disease alerts
Response	Clusters and outbreaks (e.g., MRSA, C. difficile, norovirus, TB, lice, scabies)
	Water intrusion
	Emergency and pandemic planning
	Infectious exposures from patients, other health care workers
Infectious exposures from patients, other health care workers	Vaccination (e.g., influenza, pertussis, varicella, hepatitis B)
	Bloodborne pathogens
	Product review for infection prevention

* MRSA: methicillin-resistant Staphylococcus aureus
VRE: vancomycin-resistant enterococcus
ESBL: extended-spectrum beta-lactamase producer
CRE: carbapenem-resistant enterobacteriaceae
MDR GNR: multi-drug resistant gram-negative rod